Complex Hernias

Complex Hernias are hernias which are more difficult to repair and may need special techniques, special expertise or staged procedures.

Following situations may be classified as ” Complex Hernias:

  1. Very large hernias with defect size of more than 10 cms: here since the defect is very large, it is difficult to close the defect and bring the separated muscles back to midline: these patients will need special techniques like Component separation for closing the defect and reconstructing the midline.
  2. Infected wound or mesh within the hernia
  3. Multiply recurrent hernia
  4. Large hernia in an obese patient
  5. Loss of domain, where the amount of Intestines stating outside the Abdomen ( within the hernia sac) is so large that it cannot be pushed back into the Abdomen without causing undue pressure , or even with closure of defect: these patients will need special techniques to increase the volume of Abdominal cavity before one can even think of repairing the hernia
  6. Hernia in unusual locations, non midline hernias

 

  1. Very large hernias:

When is Component Separation required?

  1. When the hernia is very large.
  2. When the hernia defect is more than 6 to 8cms, and simple primary closure is not achievable due to sheer size of defect,wide separation of Rectii or rigid Abdominal wall.
  3. When a Hernia is complicated with skin erosion, Mesh infection or bowel fistula due to mesh erosion.
  4. When Abdominal Compartment Syndrome, is imminent, anticipated, or already set in.
  5. Loss of Abdominal Domain.
  6. Non midline large Hernias.

 

What is Component Separation?

Component Separation is release of a group of Abdominal muscles so that, they can be pulled towards midline to help in closing the Hernia or Abdominal wall defect.

This concept was first proposed by Ramirez by 1990 (Reference). This was in fact an “Anterior Component Separation” This procedure involves taking an incision on external oblique Aponeurosis lateral to the Rectus Sheath ( Linea Semi lunari’s) from costal margin to inguinal region. Then it involves separating the two cut edges of external oblique aponeurosis.

This releases the underlaying internal oblique and Transversus Abdominis muscle to be fixed of its combined attachment to linea semilunari’s, yet remain attached to it, preserving the nerves passing between than intact. Then the Rectus sheath, Rectus Abdominis muscle can be pulled towards midline, and linea alba can be recreated by dosing them in midline.

This restores the Anatomical structural integrity of Abdominal wall and also the function of it.

This Anterior Component Separation Surgery can be done with an open surgery technique, or Endoscopic Technique.

The open surgery involves raising of large skin flaps to Anterior Axillary line this can lead to necrosis of around edges causing prolonged healing issues.

Endoscopic component separation on the other hand, can be done without raising skin flaps : Thus the incidence of skin flap necrosis is almost negligible and patients can go home easily.

 

Technique of Endoscopic Anterior Component Separation

This can be done either as a subcutaneous technique or sub External oblique technique.

 

Subcutaneous Technique:

  • A camera port is inserted in the subcutaneous space either in subcostal region or lateral iliac fossa, lateral to the Linea Semilunari’s
  • The subcutaneons space in expanded using a balloon,co2 or Telescopic dissection.
  • -One the space in developed from costal margin to inguinal region, additional working port is inserted.
  • Then The external oblique aponeurosis is incised (cut) lateral to the Linea semilunaris,from costal margin to inguinal Region.
  • -The edges of cut External oblique are separated.
  • -Additional dissection done between External & Internal oblique.
  • -This procedure is repeated on both sides.
  • This releases the underlying muscles so that closure of midline becomes possible.

 

 

The Sub External Oblique is approach/Technique

  • A small incision in taken generally in subcostal region,lateral to the linea semi lunaris
  • External oblique muscle in identified & incised between sutures.
  • The space between External & Internal oblique in dissected with a balloon or finger
  • A 11 mm Trocat in introduced between External & Internal oblique.
  • Telescope in introduced & co2 insufflation
  • The space between External & Internal oblique in further expanded by blunt Telescopic dissection & a working port introduced laterally.
  • The external oblique aponcerosis is incised 1 to 2 cms lateral to the linea Semi luneris from costal margin to inguinal region.
  • The cut edges are separated midely
  • Further dissection is done between External &Internal oblique
  • The procedure is repeated bilaterally

 

How wide a defect can be closed by this Anterior Component Separation

  • A defect as wide as 16cms can be closed in Umbilical region.
  • At the Xiphisternum and pubic region the defect of 8 to 10cms is all that can be closed.

 

Advantages of Anterior Component Separation:

  • It can be done in open as well as Laparoscopic Repair.
  • The Component Separation can be done with open technique or Endoscopic technique.
  • The Endoscopic Technique can be combined with open ventral Hernia Repair as well as Laparoscopic Repair.

 

Posterior Component Separation:

Although many varieties of posterior component separation have been described the TAR- Transversus Abdominis Release procedure is now taken as posterior component separation.

  • This TAR technique was originally conceived by Dr.Yuri Novistsky (Reference)
  • Yuri Novistsky discovered that

Posterior Rectus Sheath is not a single sheet but it is made up of

1 . Posterior Lamella of internal oblique

  1. Transversus Abdominis muscle fibres and aponeurosis
  2. Transversalis fascia.

Thus if you make an incision on Posterior Rectus Sheath, you will discover the Transversus muscle fibre getting inserted into posterior Rectus Sheath.

 

The TAR Procedure

  • A long midline incision is taken from Xiphisternum to Pubis.
  • Abdomen its sac of hernia is opened and adhesiolysis is done to free the Anterior Abdominal wall up to flanks.
  • The Rectus Sheath is opened at its medial edge
  • The Rectus muscle is lifted anteriorly and the Retro-Rectus space is created.
  • The neurovascular bundles going into Rectus muscle are preserved.
  • The posterior Rectus Sheath is incised in upper (caudal)part- just lateral to neurovascular bundles in order to preserve them. This incision is on the posterior lamella of internal oblique.
  • This incision opens up the space below it showing the Transversus Abdominis fibres getting inserted into Posterior Rectus Sheath.
  • These fibres are picked up or Mixture clamp bit by bit and cut releasing the Transversus muscle from its insertion.
  • This cutting of Transversus insertion is done from costal Margin to Arcuate line.
  • Then the space between Transversus Abdominis muscle fibres and Transversus Abdominis Muscle fibres and Transversalis fascia is developed by dissecting towards flank with a peanut dissector going all the way on to Posterior abdominal wall.
  • Inferiorly the dissection goes into Pelvis and Retropubic pace.
  • Superiorly the dissection continues in the sub-xiphoid area upto central tendon of diaphragm.
  • Any button holes in the peritoneum and fascia are carefully closed.
  • After completing the procedure on both sides, the midline is closed by suturing both the posterior Rectus Sheaths to each other.
  • Now a large 30X30cms Polypropelene large pore mesh is placed above the posterior Rectus Sheath and Transversalis fascia is a Diamond Shepe extending from subxiphoid region to both coopers ligament.
  • Two sutures are taken to fix the mesh to cooper’s ligament.
  • No other sutures are generally required
  • The anterior midline is reconstituted by suturing the medial edge of Anterior Rectus Sheath to ceate linea alba.
  • A complete midline closure is achieved most of the times.
  • Drains are kept
  • Peak plateau Airway Pressure are measured before and after midline closure-a difference of upto 6 is acceptable. Beyond 6 the patent will need ventilator is postop period.
  • tn case the Peak Pressure remains high, the midlilne has to be opened to prevent Abdominal Component Syndrome.

 

What are the different ways in which TAR procedure can be done?

  1. Open Surgical Technique
  2. Laparoscopic TAR
  3. Robotic TAR
  4. eTEP approach : eTEP TAR
  5. unilateral TAR- either open, Laparoscopic, eTEP, or Robotic

 

Hernias in unusual Locations like

  • Subcostal Hernia:
  • This hernia is just below the ribcage. Because it is situated near the rib cage, repairing this hernia is more difficult, and requires special techniques with more experience
  • Modern procedures like eTEP TAR are suitable for these hernias
  • A lumbar Hernia:

Other situations:

  • Hernias:
  • Symptoms of a perennial herniation:
  • • Infection
    • Constipation
    • Nausea/vomiting
    • Loss of blood offered to the intestines
    Causes of a Recurrent herniation: (hernias which occur again after being repaired)
    A herniation will appear for a range of reasons, a number of which can not perpetually be clear. the subsequent circumstances will place patients at associate inflated risk of a Recurrent hernia:
    • Infection of the wound from initial herniation surgery
  • Not using a mesh for repair
    • Chronic use of steroids
    • Chronic acute cough
    • Smoking
    • Obesity
  • infected Hernias with skin due to skin ulcer,
  •   Mesh erosion frank Mesh infection.
  • Hernias with wide defect larger than 6 to 8 cm
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